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exam saftey/document
safety and documentation chp 3-4
| Question | Answer |
|---|---|
| a patient with abnormal lab value has discharge orders. The nurse assessed the patient and called the PCP for prescription. the nurse read the phone prescription back to PCP a and verified dose. which tool did she use to prevent med error caused by comm | intro, situation, background, assessment, recommendation, read back (ISBARR) |
| POMR | Problem-Oriented- Medical Record (focused charting) |
| while documenting in the progress notes, the nurse updates only the data and action components. which component of the focus charting system did the nurse documentation neglect? | response |
| which document would help the nurse gather info from a pervious shift? | situation, background, assessment and recommendation ( SBAR) |
| The PCP instructs the LVN to medicate the patient if temp. goes above 102. In which situation would the nurse record info using SOAPIER documentation format? | Intervention |
| define subjective | info is what the patient feels; only the patient can provide this information |
| define Objective | information is what the nurse can measure and factually describe |
| define assessment | refers to an analysis or potential diagnosis of the cause of patients problem or needs |
| define intervention | or implementation is the specific care given OR action taken- EX) 102 temp given Tylenol to reduce fever |
| define evaluation | is an appraisal of the response and the effectiveness of the plan |
| define revision | includes the changes that may be made to the original plan |
| what is ISBAR? | identification, situation, background, assessment and recommendation |
| what is PHR? | personal health record- allows patient to input information into an electronic database |
| what is SOAPE? | subjective, objective, assessment, plan and evaluation |
| 23 year old with painful urination | subjective |
| examples) pt is ambulatory, well nourished | objective |
| labs and medication | assessment/plan |
| which therapeutic communication technique is nonverbal and requires extra practice by effort for nurse to use effectively? | maintaining silence |
| which space would the nurse use to elicit info during the interview process? | personal space |
| the nurse informs the patient who is scheduled for surgery that an injection of an agent that will help induce sleep will be administered before surgery. which communication technique will LVN use? | offering information |
| which example best explains a nurses respect for personal space | sitting in a chair besides the patients bed and making good eye contact |
| define paraphrasing | the nurse restates what the patient is saying to confirm whether the interpretation of the patients concern was correct. |
| restatement communication technique | the nurse is rephrasing the same message, phrasing as a question-encourages patient to continue providing info |
| when caring for patients, which factors can negatively affect therapeutic communication? | lack of trust ,language barrier, presence of pain and cultural differences |
| ADPIE | Assessment ,Diagnosis, Planning, Implementation and Evaluation |
| CBE | charting by exeption |
| COW | computer on wheels |
| MAR | medical administration records |
| NPO | by mouth |
| UAP | unlicensed assistive personal |
| AHA | American Hospital Association |
| DRG | Diagnosis Related Groups |
| JC | joint commission |
Created by:
Mallory.gonzalez21